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Vrachatis DA, Papathanasiou KA, Kossyvakis C, Giotaki SG, Deftereos G, Kousta MS, Iliodromitis KE, Bogossian H, Avramides D, Giannopoulos G, Lambadiari V, Siasos G, Papaioannou TG, Deftereos S. Efficacy, Safety and Feasibility of Superior Vena Cava Isolation in Patients Undergoing Atrial Fibrillation Catheter Ablation: An Up-to-Date Review. Biomedicines 2023; 11:biomedicines11041022. [PMID: 37189639 DOI: 10.3390/biomedicines11041022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 03/10/2023] [Accepted: 03/22/2023] [Indexed: 03/29/2023] Open
Abstract
Pulmonary vein isolation (PVI) is the cornerstone in atrial fibrillation (AF) ablation; yet, the role of arrhythmogenic superior vena cava (SVC) is increasingly recognized and different ablation strategies have been employed in this context. SVC can act as a trigger or perpetuator of AF, and its significance might be more pronounced in patients undergoing repeated ablation. Several cohorts have examined efficacy, safety and feasibility of SVC isolation (SVCI) among AF patients. The majority of these studies explored as-needed SVCI during index PVI, and only a minority of them included repeated ablation subjects and non-radiofrequency energy sources. Studies of heterogeneous design and intent have explored both empiric and as-needed SVCI on top of PVI and reported inconclusive results. These studies have largely failed to demonstrate any clinical benefit in terms of arrhythmia recurrence, although safety and feasibility are undisputable. Mixed population demographics, small number of enrollees and short follow-up are the main limitations. Procedural and safety data are comparable between empiric SVCI and as-needed SVCI, and some studies suggested that empiric SVCI might be associated with reduced AF recurrences in paroxysmal AF patients. Currently, no study has compared different ablation energy sources in the setting of SVCI, and no randomized study has addressed as-needed SVCI on top of PVI. Furthermore, data regarding cryoablation are still in their infancy, and regarding SVCI in patients with cardiac devices more safety and feasibility data are needed. PVI non-responders, patients undergoing repeated ablation and patients with long SVC sleeves could be potential candidates for SVCI, especially via an empiric approach. Although many technical aspects remain unsettled, the major question to answer is which clinical phenotype of AF patients might benefit from SVCI?
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Ikenouchi T, Nitta J, Inaba O, Kono T, Murata K, Takamiya T, Inamura Y, Sato A, Matsumura Y, Takahashi Y, Goya M, Sasano T. Effect of isolation feasibility of non-pulmonary vein foci on efficacy of ablation for atrial fibrillation: comparison of the isolation and focal ablation methods. J Interv Card Electrophysiol 2022; 65:441-451. [PMID: 35445888 DOI: 10.1007/s10840-022-01217-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 04/07/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE Atrial fibrillation (AF) mainly originates from the pulmonary vein (PV). However, some AF triggers originate from other sites, namely non-PV foci, which are related to recurrence after AF ablation. This study aimed to evaluate the effects of isolation feasibility (isolability) of non-PV foci on the efficacy of AF ablation. METHODS Overall, 1855 patients with AF (age, 64.6 ± 10.9 years; 82% paroxysmal) underwent PV isolation, followed by induction and ablation of non-PV foci. Among them, 545 (29%) patients had non-PV foci; these patients were categorized into those with isolable non-PV foci (n = 196, 36%) and those with non-isolable non-PV foci (n = 349, 64%). RESULTS During a mean follow-up of 31.2 ± 15.6 months, recurrence was higher in the non-isolable group than in the isolable group (34% vs. 19%, P < 0.01). Kaplan-Meier analyses revealed a significantly better 1-year clinical outcome in the isolable group than in the non-isolable group (88.0% vs. 78.4%, P < 0.001; hazard ratio (HR), 0.56; 95% confidence interval (CI), 0.39-0.81). This outcome was not inferior to that of patients without non-PV foci (88.3% vs. 90.8%, P = 0.81). The non-isolable group showed poorer clinical outcomes than patients without non-PV foci (78.4% vs. 90.8%, P < 0.001; HR, 1.37; 95% CI, 1.22-1.53). Cox regression analysis revealed that isolability (HR, 0.56; 95% CI, 0.36-0.89) and unmappability (HR, 2.89; 95% CI, 1.55-5.37) of non-PV foci were significant predictors of arrhythmia recurrence. CONCLUSION The isolability of non-PV foci was a significant factor affecting the achievement of better clinical outcomes following AF ablation in patients with non-PV foci.
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Affiliation(s)
- Takashi Ikenouchi
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo To, 113-8510, Japan.
| | - Junichi Nitta
- Department of Cardiology, Sakakibara Heart Institute, 3-16-1 Asahicho, Fuchu-shi, Tokyo To, 183-0003, Japan
| | - Osamu Inaba
- Department of Cardiology, Japanese Red Cross Saitama Hospital, 1-5 Shintoshin, Chuo-kuSaitama Prefecture, Saitama City, 330-8553, Japan
| | - Toshikazu Kono
- Department of Cardiology, Japanese Red Cross Saitama Hospital, 1-5 Shintoshin, Chuo-kuSaitama Prefecture, Saitama City, 330-8553, Japan
| | - Kazuya Murata
- Department of Cardiology, Japanese Red Cross Saitama Hospital, 1-5 Shintoshin, Chuo-kuSaitama Prefecture, Saitama City, 330-8553, Japan
| | - Tomomasa Takamiya
- Department of Cardiology, Japanese Red Cross Saitama Hospital, 1-5 Shintoshin, Chuo-kuSaitama Prefecture, Saitama City, 330-8553, Japan
| | - Yukihiro Inamura
- Department of Cardiology, Japanese Red Cross Saitama Hospital, 1-5 Shintoshin, Chuo-kuSaitama Prefecture, Saitama City, 330-8553, Japan
| | - Akira Sato
- Department of Cardiology, Japanese Red Cross Saitama Hospital, 1-5 Shintoshin, Chuo-kuSaitama Prefecture, Saitama City, 330-8553, Japan
| | - Yutaka Matsumura
- Department of Cardiology, Japanese Red Cross Saitama Hospital, 1-5 Shintoshin, Chuo-kuSaitama Prefecture, Saitama City, 330-8553, Japan
| | - Yoshihide Takahashi
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo To, 113-8510, Japan
| | - Masahiko Goya
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo To, 113-8510, Japan
| | - Tetsuo Sasano
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo To, 113-8510, Japan
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Ivanova AD, Filatova TS, Abramochkin DV, Atkinson A, Dobrzynski H, Kokaeva ZG, Merzlyak EM, Pustovit KB, Kuzmin VS. Attenuation of inward rectifier potassium current contributes to the α1-adrenergic receptor-induced proarrhythmicity in the caval vein myocardium. Acta Physiol (Oxf) 2021; 231:e13597. [PMID: 33306261 DOI: 10.1111/apha.13597] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Revised: 11/19/2020] [Accepted: 12/07/2020] [Indexed: 12/31/2022]
Abstract
AIM This study is aimed at investigation of electrophysiological effects of α1-adrenoreceptor (α1-AR) stimulation in the rat superior vena cava (SVC) myocardium, which is one of the sources of proarrhythmic activity. METHODS α1-ARs agonists (phenylephrine-PHE or norepinephrine in presence of atenolol-NE + ATL) were applied to SVC and atrial tissue preparations or isolated cardiomyocytes, which were examined using optical mapping, glass microelectrodes or whole-cell patch clamp. α1-ARs distribution was evaluated using immunofluorescence. Kir2.X mRNA and protein level were estimated using RT-PCR and Western blotting. RESULTS PHE or NE + ATL application caused a significant suppression of the conduction velocity (CV) of excitation and inexcitability in SVC, an increase in the duration of electrically evoked action potentials (APs), a decrease in the maximum upstroke velocity (dV/dtmax ) and depolarization of the resting membrane potential (RMP) in SVC to a greater extent than in atria. The effects induced by α1-ARs activation in SVC were attenuated by protein kinase C inhibition (PKC). The whole-cell patch clamp revealed PHE-induced suppression of outward component of IK1 inward rectifier current in isolated SVC, but not atrial myocytes. These effects can be mediated by α1A subtype of α-ARs found in abundance in rat SVC. The basal IK1 level in SVC was much lower than in atria as a result of the weaker expression of Kir2.2 channels. CONCLUSION Therefore, the reduced density of IK1 in rat SVC cardiomyocytes and sensitivity of this current to α1A-AR stimulation via PKC-dependent pathways might lead to proarrhythmic conduction in SVC myocardium by inducing RMP depolarization, AP prolongation, CV and dV/dtmax decrease.
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Affiliation(s)
- Alexandra D. Ivanova
- Department of Human and Animal Physiology Lomonosov Moscow State University Moscow Russia
| | - Tatiana S. Filatova
- Department of Human and Animal Physiology Lomonosov Moscow State University Moscow Russia
- Department of Physiology Pirogov Russian National Research Medical University Moscow Russia
| | - Denis V. Abramochkin
- Department of Human and Animal Physiology Lomonosov Moscow State University Moscow Russia
- Department of Physiology Pirogov Russian National Research Medical University Moscow Russia
- Laboratory of Cardiac Electrophysiology National Medical Research Center for Cardiology Moscow Russia
| | - Andrew Atkinson
- Faculty of Biology, Medicine and Health University of Manchester Manchester UK
| | - Halina Dobrzynski
- Faculty of Biology, Medicine and Health University of Manchester Manchester UK
- Heart Embryology and Anatomy Research Team Department of Anatomy Jagiellonian University Medical College Cracow Poland
| | - Zarema G. Kokaeva
- Department of Human and Animal Physiology Lomonosov Moscow State University Moscow Russia
| | - Ekaterina M. Merzlyak
- Shemiakin‐Ovchinnikov Institute of Bioorganic Chemistry Russian Academy of Science Moscow Russia
| | - Ksenia B. Pustovit
- Department of Human and Animal Physiology Lomonosov Moscow State University Moscow Russia
| | - Vladislav S. Kuzmin
- Department of Human and Animal Physiology Lomonosov Moscow State University Moscow Russia
- Department of Physiology Pirogov Russian National Research Medical University Moscow Russia
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Yoshida K, Baba M, Hasebe H, Shinoda Y, Harunari T, Ebine M, Uehara Y, Watabe H, Takeyasu N, Horigome H, Nogami A, Ieda M. Structural relation between the superior vena cava and pulmonary veins in patients with atrial fibrillation. Heart Vessels 2019; 34:2052-2058. [DOI: 10.1007/s00380-019-01431-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Accepted: 05/15/2019] [Indexed: 10/26/2022]
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Higa S, Lo LW, Chen SA. Catheter Ablation of Paroxysmal Atrial Fibrillation Originating from Non-pulmonary Vein Areas. Arrhythm Electrophysiol Rev 2018; 7:273-281. [PMID: 30588316 DOI: 10.15420/aer.2018.50.3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2018] [Accepted: 11/16/2018] [Indexed: 02/04/2023] Open
Abstract
Pulmonary veins (PVs) are a major source of ectopic beats that initiate AF. PV isolation from the left atrium is an effective therapy for the majority of paroxysmal AF. However, investigators have reported that ectopy originating from non-PV areas can also initiate AF. Patients with recurrent AF after persistent PV isolation highlight the need to identify non-PV ectopy. Furthermore, adding non-PV ablation after multiple AF ablation procedures leads to lower AF recurrence and a higher AF cure rate. These findings suggest that non-PV ectopy is important in both the initiation and recurrence of AF. This article summarises current knowledge about the electrophysiological characteristics of non-PV AF, suitable mapping and ablation strategies, and the safety and efficacy of catheter ablation of AF initiated by ectopic foci originating from non-PV areas.
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Affiliation(s)
- Satoshi Higa
- Cardiac Electrophysiology and Pacing Laboratory, Division of Cardiovascular Medicine, Makiminato Central Hospital Okinawa, Japan
| | - Li-Wei Lo
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital Taipei, Taiwan.,Institute of Clinical Medicine, Department of Medicine, School of Medicine, National Yang-Ming University Taipei, Taiwan
| | - Shih-Ann Chen
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital Taipei, Taiwan.,Institute of Clinical Medicine, Department of Medicine, School of Medicine, National Yang-Ming University Taipei, Taiwan
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Acute ivabradine treatment reduces heart rate without increasing atrial fibrillation inducibility irrespective of underlying vagal activity in dogs. Heart Vessels 2016; 32:484-494. [PMID: 27844147 DOI: 10.1007/s00380-016-0922-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2016] [Accepted: 11/11/2016] [Indexed: 01/11/2023]
Abstract
Ivabradine, a bradycardic agent, has been shown to stably reduce patient's heart rate (HR) in the setting of acute cardiac care. However, an association between atrial fibrillation (AF) risk and acute ivabradine treatment remains a controversial clinical issue, and has not been thoroughly investigated. Bradycardia and abnormal atrial refractoriness induced by ivabradine treatment may enhance vulnerability to AF induction, especially when vagal nerve is concurrently activated. We aimed to experimentally investigate the effects of acute ivabradine treatment with/without concurrent vagal activation on AF inducibility. In 16 anesthetized dogs, cervical vagal nerves were prepared for electrical stimulation (VS). AF induction rate (AFIR) was determined by atrial burst pacing. HR, atrial action potential duration (APD), atrial effective refractory period (ERP), and AFIR were obtained consecutively at baseline, during delivery of VS (VS alone), after intravenous injection of ivabradine 0.5 mg/kg (n = 8, ivabradine group) or saline (n = 8, saline group), and again during VS delivery (drug+VS). In the ivabradine group, ivabradine alone significantly lowered HR compared to baseline, while ivabradine+VS significantly lowered HR compared to VS alone. Contrary to expectations, there were no significant differences in trends of APD, temporal dispersion of APD, ERP, and AFIR between ivabradine and saline groups. Irrespective of whether ivabradine or saline was injected, VS significantly shortened APD and ERP, and increased AFIR. Interestingly, although bradycardia in response to ivabradine injection was more intense than that to VS alone, AFIR was significantly lower after ivabradine injection than during VS alone. We conclude that, despite its intense bradycardic effect, acute ivabradine treatment does not increase AF inducibility irrespective of underlying vagal activity. This study may constitute support for the safety of using ivabradine in the setting of acute cardiac care.
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